Failure to Post Accessible Complaint Information
Summary
The facility failed to post information on how to file a complaint with the State Agency in a manner that was accessible and understandable to residents. During a group interview with eight residents who regularly attended monthly resident council meetings, all participants indicated they did not know how to file a complaint with the State Agency and were unaware that such information was posted in the facility. One resident mentioned that concerns reported to certified nurse aides were not followed up on by the facility, indicating a lack of effective communication and resolution of grievances. An observation on the following day revealed that the required posting with the State Agency information was located in the corner of the lobby, positioned above the eyeline for residents in wheelchairs, and written in a small font, making it difficult to read. Additionally, the Social Services Director (SSD) was initially unsure of the posting's location and had to ask someone for its whereabouts. The SSD acknowledged that the posting might not be visible to residents with visual impairments but believed residents felt comfortable asking staff for assistance if needed.
Penalty
Resources
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Required postings with contact information for State agencies and advocacy groups, as well as complaint filing instructions, were placed in an area inaccessible to residents. Two residents confirmed they had never seen this information and would like access to it. The Activities Recreation Director verified that the postings were not in resident living areas and that residents did not have routine access to the posted information.
Required postings with contact information for state agencies and advocacy groups, as well as a statement about filing complaints with the State Survey Agency, were not displayed in any common areas or hallways of one house, affecting all residents living there. The Administrator confirmed the absence of these postings.
The facility did not display required contact information for state agencies and advocacy groups in accessible areas, affecting all residents. An observation confirmed the absence of postings, and the Administrator verified this deficiency.
The facility did not display required contact information for the State Survey Agency and other pertinent agencies, affecting all 65 residents. The Administrator confirmed the absence of these postings during an interview.
The facility failed to ensure that required information was posted and updated, affecting all 86 residents. An observation revealed outdated ombudsman contact details and missing information on the Medicaid fraud unit, Adult Protective Services, and complaint filing with the Ohio Department of Health. Interviews with the Ombudsman Program Director and the Administrator confirmed these findings.
Required Resident Rights Postings Not Accessible
Penalty
Summary
The facility failed to ensure that required postings, including the list of names, addresses, and telephone numbers of pertinent State agencies and advocacy groups, as well as the statement that residents may file a complaint with the State Survey Agency, were readily accessible to all residents. Observations during the annual survey revealed that these postings were located in a hallway outside of the building's interior locked doors, an area inaccessible to residents. Further observations confirmed that the postings were not present within the three locked hallways where residents were confined. Interviews with two residents during a resident council meeting confirmed they had never seen the postings or documents with information on how to contact the ombudsman or state department of health and expressed a desire to have this information. The Activities Recreation Director also confirmed that the postings were not in resident living areas and that residents did not have routine access to the area where the postings were located.
Failure to Post Required State Agency and Advocacy Group Contact Information
Penalty
Summary
The facility failed to display a list of names, addresses, and telephone numbers of all pertinent state agencies and advocacy groups, as well as a statement informing residents of their right to file a complaint with the State Survey Agency. This deficiency was identified through observation and staff interview, which revealed that the required postings were not present in any common areas or hallways of the Cornerstone Cottage, affecting all ten residents residing there. The Administrator confirmed that the necessary information was not posted, and the facility census at the time was seventeen residents. No information was provided regarding the medical history or condition of the residents at the time of the deficiency.
Failure to Post Required Contact Information
Penalty
Summary
The facility failed to ensure that all required postings, including contact information for pertinent state agencies and advocacy groups, were displayed in a manner accessible at all times. This deficiency affected all 44 residents residing in the facility. During an observation conducted on January 2, 2025, at 1:22 P.M., it was noted that there was no posted contact information for essential entities such as the State Survey agency, the State licensure office, adult protective services, the protection and advocacy network, home and community-based service programs, and the Medicaid Fraud Control Unit in any of the facility's common areas and hallways. An interview with the Administrator confirmed the absence of this information, verifying that the facility did not have a list of pertinent state agencies and advocacy groups posted.
Failure to Post Required Contact Information
Penalty
Summary
The facility failed to ensure that all required postings, including contact information for the State Survey Agency and other pertinent agencies and advocacy groups, were displayed in a manner that was accessible and understandable to residents and their representatives. This deficiency was observed during a facility inspection conducted on June 26, 2024, between 2:45 P.M. and 3:00 P.M. The absence of these postings had the potential to affect all 65 residents residing in the facility. During an interview at 3:10 P.M. on the same day, the Administrator confirmed that the required information was not posted.
Failure to Update Resident Advocate Contact Information
Penalty
Summary
The facility failed to ensure that required information was posted and updated as mandated, affecting all 86 residents. An observation on 05/01/24 at 3:30 P.M. in the common area adjacent to the 100 hall revealed a document titled 'Resident Advocate Contact Information' with outdated long-term ombudsman contact details. The document lacked information regarding the Medicaid fraud unit, Adult Protective Services, and instructions on how to file a complaint with the Ohio Department of Health (ODH). An interview on 05/02/24 at 9:47 A.M. with the Ombudsman Program Director confirmed that the posted ombudsman information was several years old. The Administrator confirmed these findings during an interview on 05/02/24 at 3:30 P.M.
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